Professional Documents
Culture Documents
Circumcision
Circumcision
Circumcision
• recognize comorbidity Gomco clamp: a steel bell (which must be the correct size) is
• recognize complications and have adequate access to medical placed over the glans after the foreskin has been fully retracted
care if such complications arise. and the perputial adhesions have been released (this sometimes
The guidelines also state that circumcisions must be performed requires a dorsal slit). The foreskin is protracted over the steel bell
under sterile conditions with adequate analgesia (preferably with and the Gomco clamp applied. The clamp crushes the foreskin
sedation or anaesthesia). In addition, the UK General Medical circumferentially (enabling the redundant tissue to be excised with
Council recommend that consent should be obtained from both haemostasis) and is then removed.
parents. Must demonstrate appropriate training and
Plastibell™ is a modification of the Gomco device. It is placed over
Social: in Australia and USA, circumcisions are performed on the the glans and the foreskin retracted back over it; it is essential that
majority of boys for non-religious ‘social’ reasons. One of the per- the correct size is used. A strong ligature is tied around the fore-
ceived advantages of circumcision is improved hygiene resulting skin into the groove on the Plastibell™ and the redundant foreskin
in a reduction in venereal disease (particularly human papilloma excised. After about 7–10 days, the foreskin edge necroses and
virus) and a reduction in penile and cervical carcinoma. separates from the ligature, and the Plastibell™ falls off.
Operative
Contraindications
The principles of surgical circumcision are:
The foreskin is used for surgical reconstruction of a number of • retraction of the foreskin
congenital penile disorders, including: • release of preputial adhesions
• hypospadias • excision of the foreskin leaving an adequate mucosal cuff
• epispadias • meticulous haemostasis
• chordee • closure.
• buried penis
• micropenis. Guillotine method: the foreskin is released. Mosquito forceps are
Circumcision is therefore contraindicated in these conditions. applied to the tip of the foreskin ventrally and dorsally and the
However it has been reported that up to 36% of hypospadiac boys foreskin protracted. A straight forcep is applied along the lower
in USA have been circumcised before surgery for hypospadias. foreskin above the glans. Care must be taken to ensure that the
glans is not caught within the forceps. The foreskin is excised by
cutting above the forceps using a large scalpel blade. The inner
Techniques
mucosa is trimmed with scissors, leaving an adequate mucosal
The aim of circumcision is to remove sufficient foreskin to expose cuff. Haemostasis is secured with bipolar diathermy. Particular
the glans whilst ensuring that penile shaft skin is preserved. attention is paid to haemostasis at the frenulum and dorsal aspect.
Only after haemostasis has been confirmed, circumferential inter-
Non-operative upted sutures are inserted using fine, rapidly dissolvable suture
‘Biblical method’: the foreskin tip is excised with a ‘knife’. Pres- (e.g. vicryl rapide). Some surgeons use tissue-glue instead of
sure is applied to achieve haemostasis. sutures for closure. Local anaesthetic gel and/or antibiotic oint-
ment is applied. A dressing is not usually needed.
The Mogen clamp is commonly used in Jewish ritual circum-
cisions. The foreskin is pulled through a slit in the clamp, which is Freehand: the foreskin is excised ventrally with scissors after a
then closed distal to the glans, allowing excess skin to be excised dorsal slit has been made. The inner mucosa can be trimmed if
before the glans is uncovered. A dressing is then applied. required. Haemostasis and closure are performed as described
above.
Complications
The majority of circumcisions are performed without compli-
cations.
Haemorrhage
Inadequate haemostasis during circumcision can result in post-
operative haemorrhage. Primary haemorrhage can be treated by:
• application of pressure to the wound
2 Paraphimosis. • returning to theatre for further diathermy
Meatal stenosis
Meatal stenosis occurs when a urethral meatal ulcer heals with
contraction of the scar or if recurrent balanitis xerotica obliterans
involves the meatus. Peripheral arterial disease, carotid artery stenosis and abdominal
Meatal stenosis may respond to topical corticosteroids, but aortic aneurysms are associated with an increased risk of myocar-
meatal dilation or meatoplasty is often required. Urethral recon- dial infarction, stroke and vascular mortality. The risk is sufficiently
struction may be necessary if balanitis xerotica obliterans has high for these conditions to be considered coronary heart disease
affected the whole urethra (rare). equivalents in various national guidelines.1
There is evidence that peripheral arterial disease, carotid artery
Incorrect amount of skin excised stenosis and abdominal aortic aneurysms are not as aggressively
Too little or too much foreskin may be removed. Insufficient treated (with respect to modification of risk factors) as coronary
removal can result in a retracted ‘penis’ and a re-circumcision may heart disease.
be required; insufficient removal also often results in poor cosmetic In this contribution, the management of the established modi-
effect. Excessive removal of foreskin can result in denuded penile fiable vascular risk factors are considered. Emerging risk factors
skin and reconstruction may be necessary. and the role of new treatments in the context of reducing vascular
events are also discussed.
Penile injury
Amputation of all or part of the glans is rare, but occurs if the glans Established vascular factors
is caught in clamp devices or if devices (e.g. Plastibell™) are incor-
rectly sized. The use of monpolar diathermy or anaesthetic agents Smoking
with adrenaline can also result in partial or total penile ablation. Smoking is a risk factor for all types of vascular disease. Peripheral
Reconstruction is attempted but, in rare cases, sex reassignment arterial disease has a particularly close association with smoking
has been necessary. because most patients (85–95%) are current or ex-smokers; the
risk of abdominal aortic aneurysms and carotid artery stenosis is
Urethral injury also increased in smokers. Smoking cessation is associated with
The penile urethra runs close to the ventral surface of the penile improved symptoms and a decrease in the need for amputations
shaft. Injury to the urethra can occur when sutures on the ven- in peripheral arterial disease. The fear of amputation is an incen-
tral side are placed too deeply, and this can result in a urethral tive to stop smoking.
fistula. Nicotine replacement therapy (gum, lozenges, patches, inhal-
ers) is a justifiable option because nicotine alone presents less
Painful scarring of a risk than continued smoking. Another option is to use the
Painful scarring occurs when the sutures have been applied to centrally acting drug, bupropion; however, bupropion has some
the edge of the glans rather than the mucosal cuff. It causes pain contraindications and potential interactions. Also, rimonabant
during erection and sometimes the scars have to be released. (an antagonist of central cannabinoid type 1 receptors) is being
developed for the treatment of obesity (decreases appetite) and
smoking cessation. The wide availability of smoking cessation
clinics in the UK that offer a comprehensive service (e.g. patient
support groups) is another advantage.